S 0523 (3) APPLICANT-f0 FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY " '
CITY,OF CUPERTINO , .�.�- - RUILDING-FA.ECTRICAL - PERMIT NO. //-�'
.y BUILDING DIVISION APPLICA , .I E{IMIT - PLUMBING-MECHANICAL S. O. L
N111L111.\C PROJECT IUF\IIFICA9'10] :
BUILDINGADDRGSS: SANITARY NO. APPLICATION SUBMI-F AL DAT
(� r►•lo 95D1
OWNER'S NAME:• PHO CONTRACTOR'S NAME LIC NO: . -
- ' NIC a COMROLa.
'CHITECT/ENGINFEIL .�� LIC ND. ADDRESS: "?- ❑
CONTACT: . . PHONE:. ,y t-. '. _',BUILDINGPERMIT.INFOO.
❑ Consonant Fera Paid by Applicant ClLfH l) BLDG PLUM I MEC
•' . • X95 0d�ib
LICENSED CONTRACTORS DECLARATION ;
QT}'r i 6LCTRIC I LR\IIT; FEC
1 hcrthY affirm thu 1 em IistuN Anda provisions of Chapter 9(mmoeac g ±.�+ v t .a - '' : `ate t JOB DESCRIPTION 4'4';
QW
WOO with Ssnan 7")e(Divisron3o1ftk B".and Ptofessiam Code,.nd my hcema,is pERyIIT ISSUANCE T
in full force and cfist - WL '-'(]KITCHEN REMODEL,
Fa-ZW Duc.C16V Conuen« ' APPLIANCES-RFSIDENIIAI. 'M , ❑PLUMBINGRE-PIPE
r MULTI-UNIT .. •' `O STRUCTURAL;`'f
ARCHfTECI'S DECLARATION
•F�Z I mdssrard my plans dull h uW as public retards - PANELS ;- i MODIFICATION:
)Z_a UP T0300 AA1PS ❑INTERIOR''. ` ❑CHIMNEY REPAIR
W utemoeti Professional 301-100DAMPS i• as IMPROVEMENT •p SWIMMING POOLS'
OWNER-BUILDER DECLARATION /, '
: Q I hereby affirm Jul I.m escmp from the Contreavr-a L ncae Law f«th< OVER HMAMPS ❑BATH RFl•10DE1/REPAIR DFMOLITION�-
.3 L U following reason.(Section 7031.5,Baines end Pmfmsiaris Cade:Any city or coarly - SIGNS ELECTRICAL �fTHFR
s0 which re9ubes a permit to condrva alter.improve,demolish,or repair may srrucaie
Sp t.,.i..gAmregiireJ .,,Baruforauch,e l,.filcecigrNswemmt SPECIALCIRCUCMISC. ` I• '
vus�y tbatheis licenWpun tioth<pmvisiomdfihe Conusmr's Littnse law(Chapter9
�CQ� (mrmtenc�ing wiU,se<tiaa'1000)ofDivision3of theBmioevend Rofwiom Code)« TEMP.METER OR POLE INST. COMMERCIAL ' J '
a o K
that he is exempt Use from wl the P.aia f«the rdRged exemption.Any vitluion of - ❑NEW BLDCVADDMON 0 DEMOLITION ^ ,
4• _amorn)0313 by any aWliceniforaµmmir subjsu�hc applicant to a civil puwlry of POWER DEVICFS t
1xy=y ❑TENANT ❑FOODSERVICE '
lar mac than five hundred"I.(5300).
F-ZY ' - IMPROVEMENT as1
6 ❑I,uo'wrty of the PrtPmtY.armY emplvYeu with mgsethcir salt carnpmuion. SWIMMING IDOL ElEC1RIC
I=.Q wdl dothcwark,endthe heC ismtimended or,vdcxe .a(Sec.)044,Uuaircna � � OTHER -
_ Pmfesaiom Code:The CarwrmY.!aconite law doe oar apply b aro owns of � OUTLETS-SWITCHES-Fl%TURPS
d 3 p;p,,,ty who builds m Impovs thereon,and who docs such woic himself or through - •-. e'...a'.'-s3,
his own unpinyar,pmvidN Jut such impuvemenu am not intended«ordered for NEW RESIDIITHAL ELECTR •SQ FT. r" 's
sok lL howeAa,thc WJdingoimprovenhewi.sand warble arc yew of compktion.the •n SQ.FTFLOORARFA '•SISQ.FT_,f
ewner builder will luAe the buidrn of pond n8 tMr he dd not tuild a improve for pus w� r V - • l -s,
,mownsof the pop^y ameweluuse]yconuringwlh limed conlna.10 �'a a s''[� �' Yr _
unmet the prolat(Sec ]W4,Business end Pmfesitons Cade)The Cammcwr'.IY yy 5, ���14"•"
ase law doe not.pply to an owner of ptopsty Who Wilda«improvm thereon.and AQTY. PI.UAIBING PERMIT • FEE '� ; /� ;f
who coousufm such pojan wth arcowasar(s)IisensN pusuant to iheCmvactofs - I D - '
I.lz I PERMITISSUANCE < _AEA -
� tempt u -.B C _ � /� ..
ALTER-DRAIN&VLM-WATER(EA) ' ." . N
WORKER'S COMPENSATION DELIARATION BACK FLOW PROIECf.•DLVICE� '� I
1 hereby affirm under pm.lty of Perjury ort of ds,follwinedslsnioe.: a, s
I have and will nuintin a CmiOc.te ofCunsent m self-insure for Worker's Comber- DRAINS-FLOOR ROOF.AREA,COND. - aSTUHU TYPE CONSTRUCTIO
'on,m provided fa by Sstioh 3700 a the Inbar Cade,lm the perfavurhee of the -
workfowhichthis .,is ivsW. Fl%TURES-PER TRAP 1. „
❑ i have and win momarm worker's Compensation hoammee,as required by Section .. .;
3700afthc labor CWe.fa the pafamuece of the wart fm which thupmnituivuN. GAS-EA.SYSTEM-I INC.4 OUTLETS. OCC:GROUP,e APN
My Wsakcla Comperdvion Imunntt ttnier and Paltry numter are: ,
Carrier. Pdicy Na.: GAS-EA.SYSTEM-0VER 6(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' ' ft
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This.cetiat reed rot he compared if the pemdtia for one hunted dollen($IM _ bUl )I ':ItsN FE!S
mlw.) OREASETRAP � PLANCHEC
I ttnify tM1at in thcpMorm.rcenfthe work(or which!hear permit is iutud,lahWl SEWER-SANITARY-STORMEA.300FT.
na employ any piton to any hunter n v m become subjst to the W«trn'Cwnpen- ENERGY
O z scion laws of Ca ifomm Due WATER HEATER WNEN7AELECf7Ft -
Q Applicant GRADING FEE
Vy NOTICE TO APPLICANT:IL afar making this Cmificvc of Esemption,you should WA1FR SYS IE TREATING
I-h " soils FEE
bsnr subject m rker'
the Woa Cmnpcm.tion Iprivisin.of the Labm Cade,you road
m
Wfomhwlth comply with Ash psovim.or this pe mit shall he deemed rtmkN. WATER SERVICE,
Q
.ate. z CONSTRUCTION LENDING AGENCY NEW RESIDEM'IAL Plh1 B. SQ.FT. PAIDq Date
U O 1lhereby idErm dot Jett is a conmsnlon lWiag agmey for the prfanwnce of .�
LL. Fthe wart for whist this peeut is iwW(sec.3097,Civ.C)
L<od is Name A
Lender's Addrev
I cenify that I have read this apPFOii.and.We that th<above itJarmuim u - .- BUIL a,--
Fah canna l agree to comply with all city std comay orditunem nd state lows relating to QTY. MI?CHANICALPEH\IIT•- •^1" FEF,...,
UsZ Widingc«uwction,and thereby authorime mgesemstives of this eery to enter upon the - - SEISMI
ebove-mmuiancd property,for impaction ptsrywes. PERMIT ISSUANCE
(We)agree to sas<,i denmiry and keep hamJw Js,City of Cupertino spatial ELECIRI
IL
IiWilitim,)ndgmsu,cmu and eapcvea which may in any way accrue against said City' ALTMORADDTOMECH.
le comcquerce of tM grtming Uthia pemtit PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING If NR(TO 10,0W CFM) MECHANIC
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCItON TAX
Slgn.mrt of AppOnnt/Conhact« h Dare EXHAUST HOOD(W/DUCT) HOUSINGMTTIGATION FE '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or brute building oecupmumreor handle h.vrdmu material HEATING UNIT(TO If1),000 BTU)
m reflnW by the Cupar a i Muncipid Code,Chapter 9.12q and the Hea th and Safety
Cade,Section n531(.d? HEATING UNIT(OVER 100.(00 BTU)
❑Ya [:1 N. VENTILATION FAN(SINGLE RESID) PAID
Doc Rct,6,
W d the epplicam m future balding by tb.Bt use egaipn Qu«dMapa which BOILER-COMP(3HP OR 100,000 BTU)
it h",,.d,Aus est caruuttituvu m defined by the Bay Arta Air Quality Mvugenent
TOTAL
sem? BOILER-COMP(OVER 100. BTI)
❑Yo ❑No - 000
I have red de bmardous materials rcquiremcnu ands Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Hearth&Safety Code Sections 15505,25533 sed 25534.1 andmuand that if the NEW RESIDENTIAL MECH. SQ.FP �/7
mf,beagdom rot whish
Y hasoatvwLNat.umYrespor.Ceritymte ofYtheoapa,,.,part FUS/
Wihe segest.cwhich man. mer pips to is myrealaibihtyneofythe ,
tTmr oremhmiW agmt Due TOT ISSUED BY:
OFFICE
Microsoft Access no-2
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Ihput Permit Number:
rPERMFr#: lRCHITECT CHARD HARTMAN] /ALUATION: F---71-73-11 ,11,,k
ENSE# ISSDATE:
APN: 36926024 ic
-US STREET: GLENVIEW SUBDATE.
E—�7 97CHKDONE:
SITUS NO#-. 10607
/E,C-F,ST,RD AV TYPE: -ATE CODE:
3LDGDEPT:
ESCRIPMON: ADDTN
N S,E,W:
-NGDEPT
NO#,. PLANDEPT
CITY: CU 11111r��ll
�LCHKREC� CMAI
ZIP'. 95014 �ATEGORY 2 CTRFIRE On'
ATED SANDIST
-OT#.
ID FmAF- -iLTHDEPT—iAN immercial 'TRCTENG
OWNER, MAHAN CA-sqftQIP
OWNER 10607 GLEWEW AV CE-sq#Mt
ADDRES CN-sQft#-. INS
YSTREETZIP. CUPERTINO CA
'HONE: -sidential
RN-sq#ft#-. 778
)NTRACTOR RE-s q#ft*
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